Cargo

During an instrument approach at night in a twin-engine turboprop airplane, the pilot reported an engine failure, but did not specify which engine. About 9 seconds later, the airplane impacted terrain about ¼-mile short of the runway and a postcrash fire consumed a majority of the wreckage. During that last 9-second period of the flight, the airplane’s groundspeed slowed from 99 kts to 88 kts, as it descended about 400 ft in a slight left turn to impact (the airplane’s minimum controllable airspeed was 92 kts). The slowing left turn, in conjunction with left wing low impact signatures observed at the accident site were consistent with a loss of control just prior to impact. Postaccident teardown examination of the left engine revealed that the 1st stage turbine rotor had one blade separated at the midspan. The blade fracture surface had varying levels of oxidation and the investigation could not determine if the 1st stage turbine blade separation occurred during the accident flight or a prior flight. The 2nd stage turbine was operating at temperatures higher than the 1st stage turbine, which was consistent with engine degradation over a period of time. Additionally, the 2nd stage turbine stator assembly was missing vane material from the 6 to 12 o’clock positions, consistent with thermal damage. All of these findings would have resulted in reduced performance of the left engine, but not a total loss of left engine power. The teardown examination of the right engine did not reveal evidence of any preimpact anomalies that would have precluded normal operation. Examination of both propellers revealed that all blade angles were mid-range and exhibited evidence of little to no powered rotation. Neither propeller was in a feathered position, as instructed by the pilot operating handbook for an engine failure. If the pilot had perceived that the left engine had failed, and had he secured the engine and feathered its propeller (both being accomplished by pulling the red Engine Stop and Feather Control handle) and increased power on the right engine, the airplane’s performance should have been sufficient for the pilot to complete the landing on the runway.

The four engine aircraft was completing a cargo flight, carrying two passengers, seven crew members and a load consisting of foods. While on a night approach to Irkutsk-Intl Airport Runway 30, the crew encountered poor visibility due to snow falls. On final, at a height of about 240 metres, the captain decided to initiate a go-around procedure when the aircraft impacted trees, stalled and crashed in a wooded area, bursting into flames. The wreckage was found about 3,1 km short of runway 30. The aircraft was totally destroyed by impact forces and a post crash fire and all nine occupants were killed.

The crew was completing a cargo flight from Mogadishu to Dolow. After landing, the crew stopped the aircraft on the runway and was able to evacuate the cabin before the aircraft would be partially destroyed by fire.

The airplane departed Juba Airport Runway 13 at 1233LT on a cargo flight to Maban, carrying five crew members and a load consisting of 28 drums of diesel. Three minutes after takeoff, while climbing, the crew declared an emergency. One minute later, the entered an uncontrolled descent and crashed less than 2 km past the runway end, bursting into flames. The aircraft was destroyed and all five occupants were killed. Registration and MSN to be confirmed. It is believed that the aircraft was operated on behalf of Euro Airlines.

The single engine aircraft departed Dekai-Nop Goliat Airport for a short cargo flight to the Dagi Baru Airstrip with two pilots on board. Weather conditions were considered as good upon arrival. After landing, the aircraft went out of control, veered off runway and came to rest down a ravine. Both occupants were injured and the aircraft was destroyed.

On final approach to Ilaga Airport, the crew encountered poor visibility due to foggy conditions. The single engine airplane impacted ground near the runway 25 threshold, lost its undercarriage and slid for few dozen metres before coming to rest on the runway. One of the pilot was killed.

The captain and first officer were assigned a two-leg overnight on-demand cargo flight. The flight crew were accustomed to flying night cargo flights, had regularly flown together, and were experienced pilots. The first leg of the trip was uneventful and was flown by the captain; however, their trip was delayed 2 hours and 20 minutes at the intermediate stop due to a delay in the freight arriving. The flight subsequently departed with the first officer as the pilot flying. While enroute, about forty minutes from the destination, the flight crew asked the air traffic controller about the NOTAMs for the instrument landing system (ILS) instrument approach procedure at the destination. The controller informed the flight crew of two NOTAMs: the first pertained to the ILS glidepath being unserviceable and the second applied to the localizer being unserviceable. When the controller read the first NOTAM, he stated he did not know what “GP” meant, which was the abbreviation for the glideslope/glidepath on the approach. The controller also informed the flight crew that the localizer NOTAM was not in effect until later in the morning after their expected arrival, which was consistent with the published NOTAM. The flight crew subsequently requested the ILS approach and when the flight was about 15 miles from the final approach fix, the controller cleared the flight for the ILS or localizer approach, to which the captain read back that they were cleared for the ILS approach. As the flight neared the final approach fix, the captain reported that they had the airport in sight; he cancelled the instrument flight rules flight plan, and the flight continued flying towards the runway. The airplane crossed the final approach fix off course, high, and fast. The cockpit voice recorder (CVR) transcript revealed that the captain repeatedly instructed the first officer to correct for the approach path deviations. Furthermore, the majority of the approach was conducted with a flight-idle power setting and no standard altitude callouts were made during the final approach. Instead of performing a go-around and acknowledging the unstable approach conditions, the captain instructed the first officer to use the air brakes on final approach to reduce the altitude and airspeed. Shortly after this comment was made, the captain announced that they were low on the approach and a few seconds later the captain announced that trees were observed in their flight path. The CVR captured sounds consistent with power increasing; however, the audible stall warning tone was also heard. Subsequently, the airplane continued its descent and impacted terrain about .70 nautical mile from the runway. The airplane was destroyed by impact forces and both occupants were killed.

On 15 September 2021, a DHC-6-300 (Twin Otter) aircraft registered PK-OTW was being operated for an unscheduled cargo flight from Douw Aturure Airport (WABI), Nabire, Papua to Bilorai Airport (WAYB), Intan Jaya, Papua. The aircraft was operated by two pilots accompanied by one engineer on board. The filed flight plan for the flight indicated that the aircraft would be operated under Visual Flight Rule (VFR) with fuel endurance of 2 hours 30 minutes. The estimate time departure for the flight was at 0640 LT. At 0610 LT, the pilot received weather observation report from the Bilorai aeronautical communication officer (ACO) that the visibility was 5 up to 7 kilometers, several clouds over the airport and all final areas were clear. About 7 minutes later, the ACO updated the observation report which indicated that the visibility changed to 7 up to 8 kilometers (km). After the cargo loading process and the flight preparation had completed, the aircraft taxied to Runway 16. At 0644 LT, the aircraft departed and climbed to the cruising altitude of 9,500 feet. Prior to the departure, there was no record or report of aircraft system malfunction. The Pilot in Command (PIC) acted as Pilot Monitoring (PM) while the Second in Command (SIC) acted as Pilot Flying (PF). At 0658 LT, the PK-OTW pilot reported to the Nabire air traffic control that the aircraft was at 25 Nm with altitude of 9,500 feet. At 0702 LT, the SIC asked the PIC to have the aircraft control as PF. During flight, the PK-OTW pilots monitored weather information provided by the pilots of two other aircraft that flew ahead of the PK-OTW to Bilorai. Both pilots monitored that the first aircraft (Cessna 208B EX) landed using Runway 27 while the second aircraft (Cessna 208B) would use Runway 09. At 0715 LT, the PIC advised the SIC to use the Runway 27 for landing. At 0719 LT, the SIC made initial contact with the ACO and advised that the aircraft was approaching Bilai at altitude of 9,500 feet and the estimate time arrival at Bilorai was 0726 LT. The ACO acknowledged the pilot report and provided current weather observation as follows “…wind westerly 3 until 5 knots, final 09 open with broken fog and final 27 open, visibility 5 until 7 km, blue sky overhead”. The SIC acknowledged the weather information and advised the ACO would report when the aircraft position was on left downwind Runway 27. At 0721 LT, the SIC read the descent checklist included the item of Landing Data/Approach Briefing and was replied by completed. The Cockpit Voice Recorder (CVR) did not record any pilot’s discussion regarding to the airport minimum safe altitude since the beginning of the recording. At 0723 LT, a pilot of DHC-6-400 aircraft registered PK-OTJ, asked the PK-OTW pilot of the weather condition in Bilorai. The PK-OTJ flew behind the PK-OTW with from Nabire to Bilorai. The SIC then responded that the PK-OTW was on descend and would fly through clouds about 5 Nm to Bilorai. Thereafter, the ACO provided traffic information to PK-OTW pilot that there was an aircraft (Cessna 208B aircraft) on final Runway 09. The PIC who acted as PF acknowledged the traffic information and advised to the ACO that the PK-OTW would join left downwind Runway 27 for the landing approach. At 0725 LT, the SIC advised to the ACO that the aircraft was on left downwind Runway 27. The ACO then advised the PK-OTW pilot to report when on final Runway 27. At 07:26:12 LT, a stall warning recorded in the Cockpit Voice Recorder (CVR) then the PIC asked to the SIC to check the aircraft speed. The SIC responded the aircraft speed was 65 knots. At 07:26:16 LT, the PIC asked to the SIC to advise the ACO that they were making a go around. The SIC then advised the ACO that the PK-OTW was making a go around and was responded to report when on final. The CVR did not record pilot’s discussion about the plan maneuver of the go around. At 07:26:45 LT, the PIC informed that they were making a go around to the PK-OTJ pilot. The PK-OTJ pilot responded that the aircraft was approaching Homeyo and would reduce the speed to make enough separation with the PK-OTW. The PIC then advised the PK-OTJ that the PK-OTW would attempt to land using Runway 09. Based on the data transmitted from the flight following system, at 07:27:57 LT, the aircraft was about 3 Nm outbound from Bilorai on direction of 238°. At 07:28:22 LT, the PK-OTJ pilot advised to the ACO that the aircraft was about 6 nm to Bilai and the pilot intended to make holding maneuver over Bilai to make enough separation with the PK-OTW. At 07:28:33 LT, the SIC advised the PIC that the aircraft was at 8,200 feet and was responded that the PIC initiated turning the aircraft. A few second later, the SIC advised to the PIC that the aircraft was turning, and the aircraft was at 3.2 Nm outbound from Bilorai. At 07:28:38 LT, the last data of the flight following system recorded that the aircraft was on direction of 110°. At 07:29:25 LT, the SIC advised the PIC to fly left. Thereafter, the SIC advised the PIC that the aircraft was passing 8,000 feet. At 07:29:35 LTC, the PIC asked to the SIC about the distance to Bilorai and was responded 2.5 Nm. The SIC, reminded the PIC to fly left as the aircraft flew too close to the terrain. At 07:29:49 LT, the CVR recorded the first impact sound and the CVR recording stopped at 07:29:55 LT. At 0730 LT, the ACO asked the PK-OTW pilot intention as the aircraft was not visible from the ACO working position, and the pilot did not respond the ACO. At about the same time, the ACO heard impact sound that was predicted coming from terrain area on west of Bilorai. The ACO then called the PK-OTW pilot several times without response. Several pilots also attempted to contact the PK-OTW with the same result. The PK-OTW was found on a ridge at elevation of 8,100 feet, about 2 Nm on bearing 260° from Bilorai.

Transair flight 810, a Title 14 Code of Federal Regulations Part 121 cargo flight, experienced a partial loss of power involving the right engine shortly after takeoff and a water ditching in the
Pacific Ocean about 11.5 minutes later. This analysis summarizes the accident and evaluates (1) the right engine partial loss of power, (2) the captain's communications with air traffic control (ATC) and the first officer's left and right engine thrust reductions, (3) the first officer's misidentification of the affected engine and the captain's failure to verify the information, (4) checklist performance, and (5) survival factors. Maintenance was not a factor in this accident. The flight data recorder (FDR) showed that, when the initial thrust was set for takeoff, the engine pressure ratios (EPR) for the left and right engines were 2.00 and 1.97, respectively. Shortly after rotation, the cockpit voice recorder (CVR) recorded a “thud” and the sound of a low-frequency vibration. The captain (the pilot monitoring at the time) and the first officer (the pilot flying) reported that they heard a “whoosh” and a “pop,” respectively, at that time. As the airplane climbed through an altitude of about 390 ft while at an airspeed of 155 knots, the right EPR decreased to 1.43 during a 2-second period. The airplane then yawed to the right; the first officer countered the yaw with appropriate left rudder pedal inputs. The CVR showed that the captain and the first officer correctly determined that the No. 2 (right) engine had lost thrust within 5 seconds of hearing the thud sound. After moving the flaps to the UP position, the captain reduced thrust to maximum continuous thrust, causing the left EPR to decrease from 1.96 to 1.91 while the airplane was in a climb. (The right EPR remained at 1.43). The captain reported that he did not move the thrust levers again until after he became the pilot flying. The first officer stated that, after the airplane leveled off at an altitude of about 2,000 ft, he reduced thrust on both engines. FDR data showed that thrust was incrementally reduced to near flight idle (1.05 EPR on the left engine and then 1.09 EPR on the right engine) and that airspeed decreased from about 250 to 210 knots. (A decrease in airspeed to 210 knots was consistent with the operator’s simulator guide procedures for a single-engine failure after the takeoff decision speed [V1]. The simulator guide, which supplemented information in the company’s flight crew training manual, contained the most recent operator guidance for single-engine failure training at the time of the accident.) The captain was unaware of the first officer’s thrust changes because he was busy contacting the controller about the emergency. The captain told the controller, “we’ve lost an engine,” but he had declared the emergency to the controller twice before this point, as discussed later in this analysis. The captain instructed the first officer to maintain a target speed of 220 knots (which the captain thought would be “easy on the running engine”), a target altitude of 2,000 ft, and a target heading of 240°. (About 52 seconds earlier, the controller had issued the 240° heading instruction to another airplane on the same radio frequency.) About 3 minutes 14 seconds after the right engine loss of thrust occurred, the captain assumed control of the airplane; at that time, the airplane’s airspeed was 224 knots and heading was 242°, but the airplane’s altitude had decreased from about 2,100 ft (the maximum altitude that the airplane reached during the flight) to 1,690 ft. The captain increased the airplane’s pitch to 9°; the airplane’s altitude then increased to 1,878 ft, but the airspeed decreased to 196 knots. The captain subsequently stated, “let’s see what is the problem...which one...what's going on with the gauges,” and “who has the E-G-T [exhaust gas temperature]?” The first officer stated that the left engine was “gone” and “so we have number two” (the right engine), thus misidentifying the affected engine. The captain accepted the first officer’s assessment and did not take action to verify the information. Afterward, the EPR level on the right engine began to increase in response to the captain advancing the right thrust lever so that the airplane could maintain airspeed and altitude. Right EPR increased and decreased several times during the rest of the flight (coinciding with crew comments regarding the EGT on the right engine and low airspeed) while the left EPR remained near flight idle. The first officer asked the captain if they “should head back toward the airport” before the airplane traveled “too far away,” and the captain responded that the airplane would stay within 15 miles of the airport. During a postaccident interview, the captain stated that, because there was no fire and an engine “was running,” he intended to have the airplane climb to 2,000 ft and stay within 15 miles of the airport to avoid traffic and have time to address the engine issue. The captain also stated that he had been criticized by the company chief pilot for returning to the airport without completing the required abnormal checklist for a previous in-flight emergency. Although the captain’s decision resulted in the accident airplane flying farther away from the airport and farther over the ocean at night, the captain’s decision was reasonable for a single-engine failure event. The captain directed the first officer to begin the Engine Failure or Shutdown checklist and stated that he would continue handling the radios. The first officer began to read aloud the conditions for executing the Engine Failure or Shutdown checklist but then stopped to tell the captain that the right EGT was at the “red line” and that thrust should be reduced on the right engine. The captain then decided that the airplane should return to the airport and contacted the controller to request vectors. The flight crew continued to express concern about the right engine. The first officer stated, “just have to watch this though…the number two.” The captain asked the first officer to check the EGT for the right engine, and the first officer responded that it was “beyond max.” Afterward, the captain told the first officer to continue with the Engine Failure or Shutdown checklist and finish as much as possible. The first officer resumed reading aloud the conditions for performing the checklist but then stopped to state, “we have to fly the airplane though,” because the airplane was continuing to lose altitude and airspeed. The captain replied “okay.” As a result, the flight crew did not perform key steps of the checklist, including identifying, confirming, and shutting down the affected (right) engine. The first officer told the captain that the airplane was losing altitude; at that time, the airplane’s altitude was 592 ft, and its airspeed was 160 knots. The captain agreed to select flaps 1 (which the first officer had previously suggested likely because the airplane was slowing). The CVR then recorded the first enhanced ground proximity warning system (EGPWS) annunciation (500 ft above ground level); various EGPWS callouts and alerts continued to be annunciated through the remainder of the flight. The captain then told the controller that “we’ve lost number one [left] engine…there’s a chance we’re gonna lose the other engine too it’s running very hot….we’re pretty low on the speed it doesn't look good out here.” Also, the captain mentioned that the controller should notify the US Coast Guard (USCG) because he was anticipating a water ditching in the Pacific Ocean. Because of the high temperature readings on the right engine, the flight crew thought, at this point in the flight, that a dual-engine failure was imminent. During a postaccident interview, the captain stated that his priority at that time was figuring out how the airplane could stay in the air and return safely to the airport. The captain also stated that he attempted to resolve the airplane’s deteriorating energy state by advancing the right engine thrust lever. However, with the left engine remaining near flight idle, the right engine was not producing sufficient thrust to enable the airplane to maintain altitude or climb. The captain’s communication with the controller continued, and the first officer stated, “fly the airplane please.” The controller asked if the airport was in sight, and the captain then asked the first officer whether he could see the airport. The first officer responded “pull up we’re low” to the captain and “negative” to the controller; the captain was likely unable to respond to the controller because he was trying to control the airplane. The captain asked the first officer about the EGT for the right engine; the first officer replied “hot…way over.” The captain then asked about, and the controller responded by providing, the location of the closest airport. Afterward, the CVR recorded a sound similar to the stick shaker, which continued intermittently through the rest of the flight. The CVR then recorded sounds consistent with water impact. The airplane came down into the Pacific Ocean about two miles offshore and sank. Both crew members were rescued, one was slightly injured and a second was seriously injured. The wreckage was later recovered for investigation purposes.

The twin engine aircraft departed Bukavu-Kavumu Airport on a cargo flight to Shabunda, carrying one passenger, two pilots and a load consisting of 1,600 kg of metal sheet. Shortly after takeoff, while in initial climb, the aircraft went out of control and crashed in a prairie located near the airport. The aircraft was totally destroyed and all three occupants were killed.